Journal of Vascular Surgery
Volume 46, Issue 5 , Pages 1077-1079, November 2007

What to do when a patient’s international medical care goes south

  • James W. Jones, MD, PhD, MHA

      Affiliations

    • Corresponding Author InformationCorrespondence: James W Jones, MD, PhD, MHA, Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
    • ,
  • Laurence B. McCullough, PhD

The Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas

James W. Jones, MD, PhD, MHA, Surgical Ethics Challenges Section Editor

Article Outline

 

There’s nothing that cleanses your soul like getting the hell kicked out of you. Woody Hayes, Former Ohio State Football Coach

A former patient who traveled to a clinic in India having placement of an Aortic endograft several weeks ago returned to your clinic with general malaise and has experienced a low grade fever. The physical examination is unremarkable but laboratory tests showed substantial evidence of smoldering infection that cannot be isolated to an organ system. MRSA grew on cultures from the groin and blood. The patient traveled abroad for therapy when you diagnosed the aneurysm because she was underinsured and remains so. You are considered one of the foremost authorities on graft infections. What should you do?

A.Tell her to return from whence she cometh.

B.Alert the news media to the problem of cheap international medical care.

C.Advise the patient to sue in international court.

D.Provide care for the patient as you would any other.

E.Advise the patient that once patients leave your care; they leave permanently. Tell her, “It is not my problem”.

Globalization is an inevitable modern reality as the economy stretches world-wide, travel cheapens, and all earthlings share common problems such as global warming. Who has not called for computer support or other technical assistance to discover they are speaking to someone halfway around the world? One will search in vain for a pair of athletic shoes or leisure clothing manufactured in the United States.

“Medical Tourism” is international economics in action as patients seeking cheaper medical care have funded a growing multibillion dollar enterprise. For many years medical care in the United States was technologically unsurpassed and the wealthy from around the world flocked here when ill. Many still do; but several decades ago medical centers in Europe began to take more of the international healthcare market share, especially from the Middle East. Currently, with the numbers of foreign medical graduates trained in the United States and the worldwide availability of technology has made American quality care available in many other countries. As new therapies are delayed by thriving American bureaucratism, cutting edge technologies often become available sooner outside the United States, including some that shouldn’t, to draw the desperate. Although mainland Europeans can freely cross borders to other member countries of the European Union, they rarely do so, even if they live on the border of another country with shorter waits for therapy.1 The Canadians and British, on the other hand, do participate in medical tourism because of lengthy delays in certain high-tech procedures. Incredibly, Americans are the largest group of medical tourists with a half million opting to leave what is assumed to be the best place for medical care in the world.2 Americans have the uninsured problem of almost 50 million, lack of coverage for cosmetic and unproven “research” therapies, and ever increasing co-pays but most travel because of the priceyness of American medical care. Far Eastern countries including Malaysia, India, and Singapore offer procedures at 20% or even 10% of the cost in the US including air fare and hotel.3, 4 Singapore has opened a second medical school to supply enough future physicians to treat the growing number of foreign patients.5

This alarming trend is reminiscent, but unlikely to be of the same magnitude, as the beating that the US auto industry suffered when car manufacturers considered themselves invincible several decades ago. Remember how they had to radically change their business plan in order to survive the competition in price and quality of foreign manufacturers. Much of the American industrial non-competitiveness still is blamed on the cost of medical care. Whether one manufactures cars or treats patients, volume eventually translates into quality.

Citizens in the United States spend almost double the percentage of the gross national product as other industrialized nations without national health statistics being as good.6 Comparing the costs by procedure between the United States and other countries can be an eye opener. For example, with respect to inguinal hernias, “it is less expensive to fly someone roundtrip from Boston to the Shouldice Hospital for three days and pay the entire bill than to have the procedure done locally.2

The American Medical Association (AMA) considered the developing crisis of medical travel outside the United States serious enough to study the problem this year and produced a report generally critical of the U.S. healthcare system. The AMA concluded that, “Currently, competition in American health care is focused not on patient outcomes but rather on shifting costs, restricting access, and supporting bloated administrative expenses.”2 In an article on international health care, Wikipedia considers the US medical economic system to suffer from adverse selection to the extent that it is a market failure.6 This economic aberration results in the unhealthy being more likely to seek health insurance (raising costs), the healthy to feel it costs too much and choosing to be inadequately insured (raising costs), and insurers expending considerable resources “weeding out” bad risks (raising costs). The only reasonable solution to systemic adverse selection appears to be the Massachusetts compulsory health insurance plan.7 Consider if property taxes were optional. Those starting families, needing schools, whose incomes were still growing would opt in, those who likely would be in a position to pay the most could opt out, raising the cost alarmingly to those trapped by the system.

Government regulation, managed care contracts, expansion of less invasive therapies, and bundling of payment for operative services have drastically reduced surgeon’s fees to a relatively small percentage of the cost of medical care while overall medical care costs continually outstrip the economy.

The surgical mindset resolutely assigns responsibilities of medical care specifically to the attending surgeon–not the assistant, resident, nurses or anesthesiologist – only to the surgeon of record. This responsibility is independent of whether other participants in care may have been causal. The natural implication is that when complications result from another surgeon’s procedure, the operating surgeon alone bears full responsibility. An infected graft is a problem no vascular surgeon wants. Why can’t the surgeon in this case simply say, “It’s not my problem”? After all, the surgeon is not causally responsible for this patient’s complication from previous treatment.

The AMA Ethics Principle VI defends the physician’s right, “except in emergencies, [to] be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.”8 Denial of treatment on the basis of HIV seropositivity is the AMA’s sole stated objection to the physician’s ethical entitlement to select the patients he or she accepts for nonemergent treatment. There is no evidence in the AMA document that a physician’s personal prejudices may be considered as a basis for or against patient exclusion.

The fourth edition of the American College of Physicians’ (ACP) Ethics Manual reaffirms the right to refuse non-emergent care to an individual patient when treatment is otherwise available.9 However, the manual states that “A physician may not discriminate against a class or category of patients.” We assume that medical tourism fails to achieve category status; the ACP has in mind race, gender, sexual orientation and other personal characteristics of patients that, if selected against, result in invidious discrimination.

Declining to treat is valid and ethically necessary when the therapy sought is unnecessary, futile, or contraindicated,10 when poor patient compliance will severely limit therapeutic effectiveness,11 or when another available physician can provide better care.12 Refusing a consultation request may also be ethically acceptable when there is a history of personal animus or other conflict of interest sufficiently negative to harm the physician’s relationship with a patient.

Rejecting a patient with an urgent need for care that one is highly qualified to provide because she had sought affordable medical care elsewhere is ethically questionable. Such a decision by the surgeon unwarrantably concludes the causality of a disease determines a physician’s professional responsibility to the patient. How the disease process came to be is irrelevant. If it were, most of us would be guilty of bringing maladies upon ourselves by our lifestyles and thus deserving our illnesses, would not deserve optimal therapy. What is relevant is that (1) the patient presented herself to the surgeon, (2) the surgeon is competent to diagnose and manage the patient’s problem, and (3) there exist, in the surgeon’s hospital, the human and technical resources necessary to provide the requisite clinical management of her problem.

Options A and E are ethically unacceptable, representing a fit of pique and not the exercise of professional or individual conscience. Refusing to treat this patient furthermore violates the professional virtue of self-effacement, which obligates the surgeon to set aside factors irrelevant to the care of the patient, especially personal ones. Where the patient received prior surgery is ethically irrelevant; she is in need of the expert clinical judgment and skills the surgeon has to offer. Option A and E also fail the Kantian criteria of universality of ethical behavior; it would not be proper for every physician to refuse to provide the best therapy because of a perceived personal insult, a trivial self-interest, at best, not valid justification for limiting professional responsibility.

Option B assumes that the patient’s infection was caused by suboptimal medical care without proof. There is some evidence that patients having transplant surgery at international medical centers do well.13 Newspaper articles are appearing that are quite complementary and one of the larger healthcare networks in Malaysia treats complications from their therapies without added charges. Is there an American hospital willing to take up that gauntlet?

Option C is a risk of having a patient’s medical or surgical care bungled in a foreign country where their malpractice tort systems are practically nonexistent; don’t expect to sue and get compensated even when compensation is deserved.3 But even with the high-powered legal system developed in the United States less than 3% of those experiencing malpractice sue and less than half of those suing receive compensation.14 However, the difference in cost between the two is billions.

Option D is the professional choice. Grumble, if needed, as you drive home about life’s injustices but taking care of patients by self-effacing will make one a better surgeon and a better person.

Also, let’s hope that changes needed in the medical establishment come about before medicine’s economic soul, like Detroit’s, improves by “getting the hell kicked out of it.”

Back to Article Outline

References 

  1. Brouwer W, van Exel J, Hermans B, Stoop A. Should I stay or should I go? (Waiting lists and cross-border care in the Netherlands). Health Policy. 2003;63:289–298
  2. AMA OMSS. Medical Travel Outside the U.S. Report B. 2007;1–20
  3. Chinai R, Goswami R. Medical visas mark growth of Indian medical tourism. Bull World Health Organ. 2007;85:164–165
  4. Burkett L. Medical tourism (Concerns, benefits, and the American legal perspective). J Leg Med. 2007;28:223–245
  5. Soo KC. Singapore’s proposed graduate medical school–an expensive medical tutorial college or an opportunity for transforming Singapore medicine?. Ann Acad Med Singapore. 2005;34:176C–181C
  6. Wikipedia. Medical care. 2007;
  7. Steinbrook R. Health care reform in Massachusetts–a work in progress. N Engl J Med. 2006;354:2095–2098
  8. Association AM. Code of medical ethics: current opinions with annotations., The Association, Chicago:, 1996.
  9. American College of Physicians. Ethics manual. In: Fourth edition. Ann Intern Med. 128:1998;p. 576–594
  10. McCullough LB, Jones JW. Postoperative futility: a clinical algorithm for setting limits. Br J Surg. 2001;88:1153–1154
  11. Jones JW, McCullough LB, Richman BW. The surgeon’s obligations to the noncompliant patient. J Vasc Surg. 2003;38:626–627
  12. Jones JW, McCullough LB. When to refer to another surgeon. J Vasc Surg. 2002;35:192
  13. Canales MT, Kasiske BL, Rosenberg ME. Transplant tourism: Outcomes of United States residents who undergo kidney transplantation overseas. Transplantation. 2006;82:1658–1661
  14. Jones JW, McCullough LB, Richman BW. From premiums to payouts: who’s behind the malpractice crisis, anyway?. J Vasc Surg. 2006;43:635–638

PII: S0741-5214(07)01460-7

doi:10.1016/j.jvs.2007.09.003

Journal of Vascular Surgery
Volume 46, Issue 5 , Pages 1077-1079, November 2007

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